Thursday, April 30, 2009

Doctor Shortage

Here, Megan McCardle plagiarizes my argument (just kidding). But she argues, like I did in early March, that universal health care will not work right now because we can't suddenly increase the total number of doctors and nurses in this country by 40%. Further, the number of GP's is decreasing and there appears to be no solution to this problem. I disagree. Megan says:
Second of all, it's actually really, really hard to pay GPs well, at least in the context of cutting overall costs. Note that private insurers, who are presumably not attempting to ingratiate themselves with the AMA, also reimburse procedures, not wellness. That's because procedures can be monitored, and wellness can't.

On the contrary, it seems to me that universal health care could fix this problem. If we all were beholden to the same standard of health care, and all medical visits, both procedural and wellness (and rehabilitation) are all billed to the same giant coffer of government health insurance, and the are all reimbursed at the same crappy rate, then it actually might encourage doctors to move to GP.
Let me explain: if you had your choice of seeing patients for $88 a visit, and look at their tonsils, check their tummy for swelling, listen to their breathing with a stethoscope, and then send them home with Tylenol (basically a zero risk consultation) or to open up their brain and try to remove a tumor, possibly killing them and getting sued, I think a lot of doctors would choose the former, not the latter. Of course, the brain surgery pays 1,000 times more. The key to universal health care would be to eliminate the ability of specialists to charge $75,000 to put in an artificial knee, or $46,000 to remove a kidney.
In many European countries, the situation is very different. There is not a desperate shortage of doctors. In Germany, for instance, every ambulance that is dispatched has a doctor riding in the back. This ensures the patient has the highest quality care possible from the moment the ambulance arrives until the patient (hopefully) leaves the hospital later. However, German doctors are not making exorbitant amounts of money. In many European countries, the job of a doctor has been reduced in stature by restriction of pay to the level of someone engineer or a scientist. So in these countries, being a doctor is a fair job, but not unlike many others.
If you want to "herd doctors to GP" as Megan puts it, you must either incentivize that trade or de-incentivize specialties enough that people stop flocking there.

The last time I talked about doctors, a commenter argued that the problem with the doctor shortage isn't as much the lock the AMA has on med school enrollment numbers, but rather the shortage of residency spots. That may in fact be true. However, residencies are typically for specialists, not for GP's. Increasing the number of residency positions nationwide simply encourages a larger share of a finite number of new doctors to specialize. Right now, we need GP's more than we need dermatologists.



Wellsy said...

No matter what kind of doc you plan to be, there is a required residency -- from neurosurgery to family medicine to pediatrics. You cannot practice medicine with only a diploma (4 years of medical school); you also need a license, and you get one of those by going through residency (3-7 years AFTER medical school, depending on field).

I think it's naive to say that we can reimburse a neurosurgeon at the same rate as a family doc. The level of technology and treatment is much more expensive, the neurosurgeon's malpractice insurance is much higher, and let's face it: the neurosurgeon is doing more. That's not to say primary care isn't important, but procedures pay more because you're doing more.

The fact that some procedures cost insane amounts of money is partly due to medical inflation, partly due to insurance companies, partly due to malpractice insurance, and partly due to general corporate greed.

When the AMA released the results of a survey last fall saying that about half of primary care docs would quit if they could, their main cited reasons were red tape from insurance and government. Reimbursement factors into that, as well, and if you think reimbursement from Medicare and Medicaid is bad (it is), just wait til everyone is on something equivalent.

The Abstracted Engineer said...

I understand that GPs have a residency. But there is not a shortage of GP residency positions. In some states, GP residents are so in demand that a med school graduate who takes a GP residency position doing rural medicine gets his/her medical school bills erased. And by "rural medicine" they mean towns with a population of 25,000 or less. Once the residency is over, the GP is free to move back to the big city.